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How to Obtain and Read Fee Schedules
List of Medicaid Fee Schedules for Downloading.
For most services, Wisconsin Medicaid
reimburses providers the lesser of the billed amount or the maximum
allowable fee established by the Department of Health and Family Services
(DHFS) based on legislative directives. The amounts established by the
DHFS are published in fee schedules, available to all providers and other
interested parties.
How to Obtain Medicaid Fee
Schedules
Fee schedules can be obtained by:
- Going to the Wisconsin Medicaid's Web site.
- Requesting paper copies of the fee schedules.
How to Read Medicaid Fee
Schedules
Wisconsin Medicaid-certified providers are reimbursed for services
provided to program recipients at the lower of their usual and customary
charge, or the maximum allowable fee.
Services reimbursed based on provider-specific (contracted rates) and
regional, or specialty-based rates are not included in these fee schedules.
Although these fee schedules do not address the various limitations
routinely applied by Wisconsin Medicaid before payment is determined
(e.g., recipient and provider eligibility, billing instructions, frequency
of services, third-party liability, copayment, age restrictions, prior
authorization), it does contain the following information:
|
PROC |
The procedure code recognized by Wisconsin Medicaid to identify
the service provided. |
|
M1/M2 |
One or two applicable modifier(s) affecting reimbursement
amount. |
|
TM |
Descriptive modifier used to convey information formerly
conveyed by type of service (TOS).
Note: In certain instances, the modifier listed is being used
both to convey information formerly conveyed by TOS and to affect
the reimbursement amount. In these instances, the modifier will be
displayed twice, once in the M1 or M2 column and once in the TM
column, even though it will only be billed once on the claim
detail. |
|
DESCRIPTION |
An abbreviated description of the procedure code. |
|
PROVIDER TYPE |
All applicable performing provider types for the procedure
code.
See Table I, included in the fee schedules, for a listing of
provider types applicable to each schedule. |
|
PAC |
The pricing action code identifies noncovered services or the
source and method of pricing the procedure. See Table II, included
in the fee schedules. |
|
EFFECT DATE |
The effective date of service on or after which the maximum
allowable fee applies. |
|
MAX FEE |
Maximum allowable fees for the procedure codes listed. If a max
fee is not indicated, use the PAC and Table II to determine the
reason (e.g., PAC 220 indicates service not covered, PAC 21j
indicates individual consideration). |
This information is intended to help you understand the Wisconsin
Medicaid Maximum Allowable Fee Schedule. If you have questions, please
contact Wisconsin Medicaid Provider Services at (608) 221-9883 or (800)
947-9627. When requesting information, please be specific as to which
provider type you are referring (e.g., Ambulance).
Reminders:
When using the fee schedules, remember the following:
- HMOs negotiate rates with their individual providers,
and these rates may differ from Wisconsin Medicaid's fee-for-service
rates. Contact the HMO or check your contract with the HMO for their
reimbursement rates.
- Wisconsin Medicaid requires most providers to bill
their usual and customary charge for services provided to Medicaid
recipients. Therefore, providers should not use the fee schedules to
set their rates. "Usual and customary charge" means the
provider's charge for providing the same service to persons not
eligible for Medicaid benefits.
- Reimbursement rates may change during the year.
Wisconsin Medicaid notifies providers of significant rate changes.
- Different areas of a provider's office, such as
billing and medical services, may have different uses for these fee
schedules. Please share these schedules with appropriate staff.
Download Fee Schedules From the
Wisconsin Medicaid Web Site
Follow these steps to download a text (.TXT) or portable document
format (.PDF) fee schedules from the Internet:
- Click on the appropriate fee schedule file
name which ends with the extension .TXT or .PDF.
- Portable document format files can be viewed in the
software program Adobe
Acrobat Reader®. If your Acrobat Reader® supports the option to
automatically open the file, the Acrobat Reader® will appear
in the browser. If your Acrobat Reader® does not support the
feature of automatically open the file, a window will appear asking where to save the
.PDF file.
- Text files can be viewed in any text editor.
Learn
more about PDFs.
Requesting Paper Copies of the Fee Schedules.
To order a paper copy of a fee schedule use
the
Maximum Allowable Fee Schedule Order Form
(PDF).
Back
to the fee schedule list
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